Healthcare Provider Details

I. General information

NPI: 1871598516
Provider Name (Legal Business Name): KENNETH LEROY HOLDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E CALAVERAS BLVD
MILPITAS CA
95035-5412
US

IV. Provider business mailing address

420 E CALAVERAS BLVD
MILPITAS CA
95035-5412
US

V. Phone/Fax

Practice location:
  • Phone: 408-262-6800
  • Fax: 408-262-6007
Mailing address:
  • Phone: 408-262-6800
  • Fax: 408-262-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: